Addressing Social Determinants of Health through Screening and Resource Referrals



Serious illness outcomes reflect pre-existing racial and ethnic disparities in healthcare access and quality in our communities. Minority populations are more likely to receive unhelpful aggressive care at end of life (EOL), more likely to receive care requiring care transitions, less likely to complete advance directives, and less likely to enroll in hospice. The factors that contribute to disparities in EOL care are complex, and include health system issues, care provider considerations, policy considerations, and cultural issues.

Social determinants of health (SDOH) are closely linked to health outcomes among populations historically exposed to health care disparities, and they present actionable targets for enterprises committed to improving care for all people living with serious illness. The Ascension team addresses SDOH barriers and the needs of community members through the implementation of a systematic SDOH screening and resource referral process.

Project Team

Sara K. Damiano, LMSW, CCM, ACHP-SW
National Director, Palliative Care
[email protected]

Elizabeth Kvale, MD, MSPH
Section Chief, Palliative Care
Livestrong Cancer Institutes of the Dell Medical School, The University of Texas at Austin

Paul Tatum, MD
Associate Professor of Clinical Medicine, Division of Geriatrics and Palliative Medicine
Ascension Health and University of Texas


Bronze Winner, Planning Stage


Reaching the Patients in Need